Proactive Medication Management is Essential in Elderly With Fragility Fracture and Osteoporosis
Older adults face a “crisis in osteoporosis care,” according to experts at the annual meeting of the American Society for Bone and Mineral Research. While multiple concerns were raised, one of the most shocking is the evidence showing that fragility fractures and osteoporosis aren’t being treated properly.
A significant problem centers around lack of medication oversight. Sometimes bone-strengthening drugs aren’t used when appropriate; other times, medications are prescribed following a fragility fracture that increase the risk of osteoporosis. Proactive pharmacist intervention and patient counseling may help protect elderly patients with osteoporosis from multiple fragility fractures.
Current Crisis in Osteoporosis Care
When the American Society for Bone and Mineral Research (ASBMR) convened in September 2016, they discussed the impact of reimbursements cuts for dual-energy x-ray absorptiometry (DEXA), which is the gold-standard used to screen for osteoporosis.1 The bottom line is simple: the costs to operate DEXA couldn’t be sustained following a 70 percent reduction in reimbursements. As a result, about 2.3 million fewer screening tests are done now compared to in 2009.
Treatment for osteoporosis is also in crisis. As one example, only about 10 percent of Medicare patients received treatment in the 6 months before or after sustaining a fragility hip fracture. Bisphosphonates are the most commonly prescribed medications and for good reason—they reduce fractures by 20 to 70 percent, depending on the bisphosphonate used, site of the fracture and the individual risk profile.2 Yet bisphosphonate use declined by 50 percent, a statistic that’s attributed to patient refusal and doctors writing fewer prescriptions as they learned about complications such as osteonecrosis of the jaw and atypical femur fractures.
Meanwhile, a study published in the October 2016 issue of JAMA Internal Medicine shed light on the extensive mismanagement of medications following hospitalization for a fragility fracture.3 This retrospective cohort study included more than 168,000 Medicare beneficiaries who survived a fragility fracture of the hip, shoulder or wrist and lived in the community for at least 30 days after discharge. After looking at the drugs prescribed for these patients in the four months before and after their fracture, the researchers found:
In the four months before fragility fracture:
- 75 percent were taking medications that increased their risk for fracture, including antihypertensives, sedatives, steroids, tricyclic antidepressants and proton pump inhibitors.
- Fewer than 25 percent used drugs to strengthen bones.
In the four months following the fracture:
- Only 22 percent were prescribed bisphosphonates.
- About 7 percent discontinued nonopioid drugs associated with high osteoporosis risk.
- About 7 percent were newly prescribed similar nonopioid drugs.
- Which resulted in a static 77 to 80 percent who used at least one drug that increased their risk for osteoporosis before and after a fragility fracture.
What Pharmacists Should Know About Fragility Fracture and Osteoporosis
Osteoporosis is the top cause of fragility fractures, which are often called low-energy fractures because they’re caused by a fall from standing height or less—a mechanical force that wouldn’t result in a fracture unless the bones were unusually fragile. Prevalence rates tend to vary because an estimated 80 percent of those who have an osteoporosis-related fragility fracture are not identified or treated, likely due to the fact that two-thirds of vertebral fractures are often asymptomatic. Here are the current numbers:
- One in three older women and one in five older men experience a fragility fracture after age 50.
- The total number of fragility fractures exceeds 2 million per year in the United States.4
- Following the first fragility fracture, patients are twice as likely to suffer a second fracture.5
Statistics that tally fragility fractures in ambulatory health care centers and physician offices show that hospital discharges account for only 18 percent of the fractures treated.6 Additionally, wrist and arm fractures are the most common sites treated in outpatient settings. By comparison, hip fractures account for 23 percent of hospitalizations, followed by fractures of the spine, humerus, pelvis, femur, and wrist. Hip fractures carry a high risk of mortality—21 percent die within the first year. Mortality goes down beyond the first year, although it stays higher compared to other adults who haven’t had a fragility fracture. Of those who survive, about 30 percent lose their independence.
Medication Therapy Management to Prevent Fragility Fracture
A study in the October 2013 issue of the Journal of the American Geriatrics Society reported that a “fracture was insufficient to trigger effective secondary prevention” in elderly Medicare patients.7 While age, risk factors, and overall health must be considered in treatment decisions, and there are some contraindications to bisphosphonates, such roadblocks don’t explain the fact the fact that only 22 percent of older patients receive any type of testing and/or pharmacotherapy within six months following a fragility fracture.
The circumstances practically scream for pharmacist intervention. Many Medicare patients will qualify for medication therapy management; those who don’t still depend on a basic review of their medications. Elderly patients must be evaluated to see if they’re being treated for osteoporosis following a fragility fracture and whether they continue to take medications that increase the risk for osteoporosis, fractures, and falls. Then pharmacists need to collaborate with physicians to see if medication therapy can be adjusted to reduce the risk. The list of drugs that can cause osteoporosis includes:
- Glucocorticoids – 30 to 50 percent of patients taking these agents develop fractures
- Proton pump inhibitors
- Selective serotonin receptor inhibitors
- Medroxyprogesterone acetate
- Aromatase inhibitors
- Androgen deprivation therapy
- Calcineurin inhibitors
Assessing the risk for fragility fracture – As you evaluate medications, you can also assess the risk for a fragility fracture. The Fracture Risk Assessment Tool (FRAX) was developed by the World Health Organization to calculate the 10-year probability of fragility fracture in patients who have not yet experienced a fracture.8 You can use FRAX guidelines to recommend testing for bone mineral density (BMD) or, if the FRAX score reaches the upper assessment threshold, primary care physicians can consider treatment without further tests. Results from the FRAX assessment are comparable to the use of BMD alone.
Pharmacist Intervention Lowers Patients’ Risk for Fragility Fractures
Patients who have had a fragility fracture face a greater risk of subsequent fractures. Many other elderly patients are also at a high risk for osteoporosis and fragility fractures, but they’re not aware of the threat. Prescription and OTC drugs, along with lifestyle factors like exercise and taking calcium with vitamin D are all modifiable factors that can be changed to improve their odds, but this will only happen when pharmacists reach out with patient counseling and medication management.
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- “Crisis in Osteoporosis Care Will Be Key Theme at ASBMR 2016,” September 2016, http://www.medscape.com/viewarticle/868549 ↩
- “Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research,” January 2016, http://onlinelibrary.wiley.com/doi/10.1002/jbmr.2708/full ↩
- “Patterns of Prescription Drug Use Before and After Fragility Fracture,” October 2016, https://www.ncbi.nlm.nih.gov/pubmed/27548843 ↩
- “Epidemiology of Fracture Risk with Advancing Age,” October 2013, https://www.ncbi.nlm.nih.gov/pubmed/23833201 ↩
- “University of Michigan Health System, Fragility Fracture Clinic,” accessed December 2016, https://medicine.umich.edu/dept/orthopaedic-surgery/patient-care-services/trauma/fragility-fracture-clinic ↩
- “Prevalence of Fragility Fractures,” 2014, accessed December 2016, http://www.boneandjointburden.org/2014-report/vb1/prevalence-fragility-fractures ↩
- “Quality of Osteoporosis Care Among Older Medicare Fragility Fracture Patients 2006-2010,” October 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4084674/ ↩
- “Fracture Risk Assessment Tool,” accessed December 2016, http://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Fracture-Risk-Assessment-Tool-FRAX ↩